Avon House

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

Well-led – this means we looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture.

At our last assessment we rated this key question good. At this assessment the rating has remained good. This meant the service was consistently managed and well-led. Leaders and the culture they created promoted high-quality, person-centred care.

This service scored 71 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

Staff were consistent in their understanding that providing person-centred care was the focus of the service. Staff spoke proudly about the service and told us, “The best thing about this place is the standard of care we provide,” and “People here do get very well looked after and they are happy here.” There was a positive and open culture, staff described feeling included and said their ideas were listened to. A staff member told us, “It’s a positive place to work, if there’s a problem, we discuss it together and a solution is found.”

The provider had inclusive leaders at all levels who understood the context in which they delivered care and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

The registered manager was knowledgeable about people’s individual needs and had a good awareness of the current issues for people.

Staff spoke highly of the management of the service and the support they received. One staff member said, “They (registered manager) are very approachable and always listening to us.” Another staff member said, “We are all supported and treated fairly.” One staff member described the support they had received, saying, “A manager will sit with me and go through things if I don’t understand. It has given me confidence and brought me out of my shell; I love working here.”

The registered manager told us staff support was a high priority for the provider. This included access to external support through an Employee Assistance Programme. Staff were also able to attend a well-being hub where they could access physical health programmes as well as support for their mental well- being.

The provider fostered a positive culture where staff felt they could speak up and their voice would be heard.

Staff described feeling well supported and said they were able to raise any issues or concerns and had confidence that appropriate actions would be taken. One staff member told us, “Any good ideas are listened to and implemented.” They gave an example about a change in staff deployment that had been suggested, saying, “It’s working better now, and the work is divided up more fairly.” Another staff member told us, “We have opportunities to speak up in team meetings or in individual supervision meetings, everything is discussed and considered.”

The provider valued diversity in their workforce. They worked towards an inclusive and fair culture by improving equality and equity for people who worked for them.

The provider had recruited a diverse workforce and promoted a fair and equitable culture. Staff told us they were treated fairly and felt valued by the management. One staff member described having difficulties with processing information which affected their ability to undertake some kinds of training. They described how adjustments had been made to support them to complete the necessary training they needed.

The provider did not always have clear responsibilities, roles, systems of accountability or good governance.

Systems for monitoring risks were not always effective. Some environmental risks had not been identified through the provider’s governance systems. We spoke with the registered manager about this, and they took immediate actions to mitigate risks and ensure people’s safety.

The registered manager had good oversight of the service. Staff described the registered manager as being “hands on” and easy to approach. One staff member said, “The good thing here is all the staff muck in, including the seniors and manager, if we are struggling, they help out.” The registered manager demonstrated they knew people well and understood their needs.

Incidents were investigated and evaluated to identify the cause and any patterns or trends. Appropriate measures were put in place to reduce the risk of further incidents. A service improvement plan documented changes that had been identified through the provider’s systems for governance and quality monitoring. For example, a health and safety check had identified the need for new equipment and staff told us a new hoist was on order.

Staff understood their roles and responsibilities and the registered manager was clear about their regulatory responsibilities.

The provider understood their duty to collaborate and work in partnership, so services worked seamlessly for people. They shared information and learning with partners and collaborated for improvement.

Staff described working in partnership with health and care professionals. Records showed collaborative working for example, with a local hospice. Referrals were made in a timely way when people needed to access services.

People and their relatives described how staff involved them in planning care and support. One person’s relative said, “They (staff) go through everything. There is no other home that makes your relative feel like part of the family.” They described effective communication systems to keep them informed. For example, one relative described how social media was useful for them to see what activities their family member was taking part in. They said, “There is always so much going on.”

People were supported to remain part of the community both within the service and out in the wider community. A relative told us how staff supported people to maintain important links, for example, by attending a local church service. Another relative described how staff supported people to feel involved. A person living with dementia believed they were working at Avon House, so staff provided them with a timesheet and discussed having breaks and working overtime. Their relative told us, “It’s those things that make all the difference, these little touches matter.” One relative told us about “relative’s days,” where they could meet other relatives. They said, “We would be introduced to each other and talk to others who are in the same position as us.” They described how this provided them with support and reassurance.

The provider focused on continuous learning, innovation and improvement across the organisation and local system. They encouraged creative ways of delivering equality of experience, outcome and quality of life for people.

There was a strong focus on learning and development at the service. Staff had regular opportunities for reflection and learning from practice. For example, one staff member described the support they received when providing end of life care. This gave staff an opportunity to consider what had gone well and where improvements could be made to enhance people’s end of life care in future. They spoke about additional training that would be useful and the registered manager told us this was being arranged.

Some staff were trained as champions in specific topics including end of life care, medication, oral health care and well-being. This promoted good practice and provided a contact point for people, their relatives and staff to gain additional information or advice about particular areas related to people’s needs.

The registered manager told us they were part of a group of registered managers who regularly discussed practice issues and shared learning. They explained how this had been beneficial in developing improvements at the service. For example, the registered manager had developed a winter plan to support contingency planning and preparedness for the additional risks associated with wintertime. This included consideration of vaccinations for people and staff, contingency planning for staffing and recruitment and environmental issues.

The registered manager also took account of learning from incidents and issues in other care homes to make improvements at Avon House. For example, they described how they had reviewed and improved care plans for people who required modified diets to ensure information was consistent and comprehensive. As a result, all staff had received additional training in modified diets and risks following an incident of choking in another care home. We noted how staff were knowledgeable about people’s nutritional needs and how to manage risks of choking. We observed staff supporting people with modified diets in line with their care plans which were comprehensive, detailed and well personalised.